02100089 CITY OF CUPEWFINO -'- %bop . st
RUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
IIuB_110aN81g1gSlSTOKES AV JUST WATER HEATERS INC PERMirN(02 10 0 0 8 9
owrOOHA+R YORAM AND ZAHAVA 1764 NATIONAL AVE Apr1ICATIV "Tai 2002
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[ONE 5 1 0 2 9 3 -9 9 0 1 SANITARY NO. CONTROL NO,
ARCl11'11iCTIENGINEFR: BUILDING PERMIT INFO
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LICENSED CONTNAC"I'OR'SDECLARATION fHr,'A�p� pon
rc-F I Wreby affirm that l am licensed under uminshms of Chapter 9(commencing REPLACE WATER
taiwith Section 700L,f Division J of the Business and Professions Cdr.and my license is
in full bece and dfico.
O Zi License Class [.it.it
F, Dale Contract...
n ARCHITECTS DECLARATION
ed< I undenstand my Plans shall W used as public records
3au
FLLOF_ Licensed Professional �aryAry� `
dd OWNER BUILDIiR DIiCLARATION R`I Jp' ialtt
hereby affirm that I am cacmpt from the Corthoelnr's License Law lin the $4 /U
Pi
6 a O fallowing reason.(Section Aq 1.5.Business and Professions GNe:Any city or county
e%m which requires a scroll at construct.alter,improve,demolish.or repair any structure
=_y prior m its issuance.also requires thcappllcant lor.such Permit In file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law pCmptc'9 3S'2{6F1.� 6AT8� ahation
aZ� (commencing with Section 7100)of Division 3 of the Business and Professions Code)to
i $ that he is exempt Ihcmfrom and Ne basis for the alleged exemption.Any violation of 11off n a n.
Section 7031.5 by any applicant for a permit.subjects the applicant In a civil penally of PMN 'fancy Type
not mom than Eve hundred dollars(ssm). 506 — GAS TEST
0 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and Ne structure is not intended or offered for sale(Sec.7044,Business
and Professions Co ,eeThe Contractors License Law does not appy to an owner or egmre nspecti0ns
property who builds or improves thereon,and whodess such work himmiror through his
own employers,provided that such improvrmcers afe not inmmled nr Clferrd fur saleIf.
however,Nr Wilding or improvement is sold within one year of compbe ion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
0 I.as ovrcr of Ne pM,rny,am exclusively contracting with licensed ennvacmrs to
construct the project(Sec.7044,Business and Professions Code:)The Contracmr's Li-
cense Law does net apply to an owner of property who Wilds or improves Ihercon,and
Who conmacts for such pmjccts with a contractors)licensed pursuant to 104 Contractor's
Licenm Law.
0 1 am exempt under See. .B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby alarm under Penally of perjury one of the following deelaradons:
0 [haw and will maintain a Certifrcare of Covent to eh.-insure for Worker's Compere
ration,as provided for by Section 3701 of the Lalxn Code,for the Performance of the
work for which this permit 1s issued.
❑1 have and will maintain Worker's Compensation Insurance,.acquired by Section
3710 of the Labor Code,for the Nuormance of the work for which this permit is issued
My Worker's Compensation Inspmnce tinier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMITION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if IW permit Ls for one hundred Jnllars(S IIKB
,r lcsxJ
1 certify Nat in the perbmmance or tbo work for which this permit is issued,1 shall not
employ any prison in any manner so as ht WCMW subject o the Workcri Compensation
Laws nl California,Date
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should
become subject I)the Worker's Compensation provisions of the Labor Cade,you must
OZ forthwith comply with such previsions or this Permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
PgO I hereby allirm thus there is aamstruction lending agency lin the penivmance of
IZ > ft Work far which this permit is issued(Sec.30N7.Co.CJ
W Q Under Name
(>•,
l.enJCrs Address
LD z
J C 1 certify Nat 1 have read this application and state that the above information is
D. F correct.1 agree to comply with all city and county ordinances and stare laws relating to
0 building construction.and hereby autWnse representatives of Ws city to culerupon the
{+1 xbovomentioned properly lar inspection purposes.
(Wr)agree to save,indemnify and keep harmless the City of Cupenino against
Iiabilitics.judgments.costs and Cxpenscs which may in anyway Beane agaimataid City
U Z in nmseq.ence nl the grunting of Ihis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of AppliraDate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant rfuture building Code Chaptsome r9L1or hanand to Health ad
Code
section
the Cuprninn Municipal Ctxk,Chapter Y.12.and the Health and Safety
CnJc.Section 255ffi(a)'! All roofs shall be inspected prior to any roofing material being installed.
❑Yin Otho
Will thea ant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
�.J it m s p
emit W,amoar air contaminants as JcfincJ by the Bay Arca Air Quality Management all new materials for inspection.
Dialnn7
Oyes 0 N
1 have mail the hazardous macrials mgnlmmenls under Chupler 6.95 of the Culibn-
ma Health&Sale,y Qde.Sccmms 25515,25537 and 15574.1 uvkrsfand thin if dw building
docs nal surrenal,hour a manor,thm b is my respumiMlay m notily 104 occupant ul the
requhrments which most W mel Pnosmh.suaooe of a Ccmficam of CxCCPnq. Signature of Applicant Date
Owner or authnrimd agent Dale I All roof coverings to be Class'B"'or better